Emergency Medical Services
Joseph Sabato, Jr, MD
Assistant Professor of Emergency Medicine
Director of Special Operations
Mary Tang, MD, MPH, PGY-3
Robert Williams, MD, PGY-3
1966 National Highway Safety Act
Authorized the US Department of Transportation
(DOT) for prehospital medical services to fund:
Emergency Medical Services
Systems Act of 1973
(public law 93-154)
Funded and authorized the Department of
Health, Education and Welfare to develop
EMS throughout the country.
Public Law 93-154
Identified the following 15 components as
essential to an EMS system:
Communications Transfer of care
Training Consumer participation
Manpower Public education
Mutual aid Public safety agencies
Transportation Standard medical
Critical care units
911 Emergency telephone number
essential front door of the EMS system
Enhanced 911 (E-911) equipment
provides automatic number and location
Emergency Medical Dispatch
Based on the principle that good information
gathering during the dispatch phase of an
emergency can better prepare responding EMS
providers to deal with the situation at the scene.
Deliver basic emergency care instruction to
people on the scene.
Prioritize request for emergency medical
Ensure only appropriate agencies or prehospital
providers are dispatched.
Emergency Medical Dispatch (cont’d)
May be carried out by a variety of
Law enforcement agency (LEA)
Separate public safety dispatch center
Why is 911 better than dialing “0” ?
1st: Additional call and routing process,
which takes precious time.
2nd: The caller may not be connected with
the correct jurisdiction or service that
EMS system access
Cardiopulmonary resuscitation (CPR)
First responders (FRs) followed by ambulance
FRs: Firefighters, police, park rangers, or citizen
Emergency Medical Technician (EMT):
EMT basic (EMT-B) - CPR, AED, extrication, immobilization
EMT intermediate (EMT-I) - IV access, PASG
EMT paramedic (EMT-P) - Intubation/RSI, EKG,
synchronized cardioversion, manual defibrillation,
& drug therapy
Public interest and participation:
Key ingredients in any EMS system!
Public safety and
Rural or wilderness
Volunteers, park rangers,
or ski patrols.
Mutual Aid Agreements
EMS services have agreements with
neighboring jurisdictions so that
uninterrupted emergency care
is available when local agencies are
overwhelmed and/or unable to
Provide most EMS transportation.
The most important aspect of ambulance
design is that the attendants must be able to
provide airway and ventilatory support while
safely transporting the patient.
Access to Care
A successful EMS system ensures that all
individuals have access to emergency care
regardless of their ability to pay or type of
Emergency physicians must serve as the
Transport to the closest appropriate hospital.
If multiple hospitals within the same transport time:
Specialized receiving facilities
Higher level of care warranted
Transport to that institution (by passing closer hospitals).
• i.e. trauma, burn, stroke or angioplasty center
Critical Care Units (CCU’s)
Tertiary care facilities should be identified by every
EMS system to provide specialty care that is not
available in typical community hospitals.
Most common reasons for tertiary care emergency
Neonatal intensive care
Spinal cord injury
Pediatric Specialty Hospitals
Transfer of Care
Must be made with maximum
safety for the patient!
Laypersons should be represented on EMS
Two important components of a successful
Lay public first aid training
Implementation of a 911 system
Public Information and
In designing a public information program, the
EMS council’s goal should be for the public:
3. Understand how the community stands to
benefit from an excellent EMS system.
4. Be prepared to render first aid care.
5. Know how to access the EMS system quickly.
6. Understand that patients may not be delivered
to the hospital of their choice under life-
Public Safety Agencies
Strong ties with police and fire departments
Often provide first-response service because
their personnel are often the first on the
scene of an emergency.
I.e., police carrying oxygen and automatic defibrillators
All ambulance services within a specific
region should use a similar reporting form
that can be quickly and easily be
interpreted by receiving nurses and
The EMS system is an integral element of disaster
preparedness and planning.
Important role in initial response and transportation
Establish a regional disaster preparedness plan in coordination
with public safety agencies, government and medical
Disaster management, communication, treatment and
destination of casualties
Periodic disaster drills
The process by which a dedicated physician(s) guides and
oversees the patient care that is provided by an EMS system.
Why do paramedics, who are licensed by the state,
need a medical director or physician advisor?
On-line Medical Direction (OLMD)
a.k.a. direct medical control,
on-line medical command, or
real-time medical control.
Direct medical communication to personnel in
• landline (traditional telephone)
Off-line Medical Control
Responsibility of the service medical director
2. Development and implementation of
protocols and standing orders
3. Development of medical accountability (QA)
4. Development of ongoing education
initial and recertifying training programs.
Physicians must remember that they have the
ultimate responsibility for the overall quality of
prehospital medical care.
Qualifications of an EMS
Licensed physician with interest, experience,
and knowledge in emergency medicine and
Preferable if full-time, practicing, emergency
physician at the lead hospital for the EMS
system, with additional training and experience
Emergency Cardiac Care
ALS saves lives after sudden cardiac arrest.
The number of lives saved and the cost are debated.
Without treatment at the scene, the survival rate of out-of-
hospital cardiac arrest is virtually zero.
Seattle and King Count, Washington
26% patients successfully resuscitated from out-of-hospital cardiac
New York City
1.4% overall survival
Outcome of out-of-hospital cardiac arrest in New York City. The
Pre-Hospital Arrest Survival Evaluation (PHASE) study.
JAMA 1994 Mar (Lombardi, Gallagher, and Gennis)
Recommended for witnessed cardiac arrest
(Vtach, Vfib) with spontaneous return of
Administer as soon as possible, i.e, pre-hospital
with ice packs to groin, axillae, and neck
Howes et al. "Evidence for the use of hypothermia after cardiac arrest." CJEM
Minimal Interruption of CPR
MICR = initial series of 200 uninterrupted
chest compressions, rhythm analysis with
single shock, then 200 post-shock
compressions before pulse check or
rhythm-reanalysis; also done before
admin of epi, intubation
Shown to improve survival in out-of-
hospital cardiac arrest
Bobrow et al. “Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital
Cardiac Arrest.” JAMA 299(10)1158-1165.
Shorten interval between collapse and defibrillation.
Local system must optimize the “chain of survival”
Jim Alexander - Security officer
Las Vegas security officer saves two lives in less than
U.S. Air Force retiree Jim Alexander works as a security
officer at Stardust Resort and Casino in Las Vegas. In less
than one year, Alexander saved the lives of two casino
guests: one in September 1997 and another in August 1998.
Delivery of critically injured trauma patients to
trauma centers saves lives.
Controversial: IV on scene (field) vs. en route
Houston: no IVF in Prehospital or E.R.
for hypotensive victims of
penetrating truncal trauma.
EMS For Children
Leadership in the area of injury and illness prevention
Leadership in local, regional, and state EMS and EMSC systems by
involvement in the provision of medical direction (oversight),
education of providers, quality improvement, and legislative
Collaboration with other physicians and health care professionals to
enhance the medical home for children, including referral to
primary care, specialized care, and rehabilitation services
Research in the design and function of EMS systems, education of
providers, out-of-hospital and emergency care interventions, and
outcomes of emergency care
Expertise for and collaboration with the National EMSC Program
(Maternal and Child Health Bureau in collaboration with the
National Highway Traffic Safety Administration)
“The Chain of Survival”
In 1990, the American Heart Association introduced a
treatment model for victims of sudden cardiac arrest called
the Chain of Survival. It outlines the specific sequence of
events that need to happen for a victim to survive and
recover from sudden cardiac arrest.
The Chain of Survival
Early Access: Someone suspects or determines the victim
is in sudden cardiac arrest and calls for help
Early CPR: Someone trained in CPR keeps the victim’s
blood flowing until defibrillation can begin
Early Defibrillation: Someone trained in defibrillation
shocks the victim as quickly as possible
Early Advanced Care: Medical personnel provide
advanced cardiac care which can include airway support,
medications, and hospital services
Automated external defibrillators (AEDs)
analyze the patient’s rhythm, determine whether a defibrillatory
shock is indicated, charge the capacitors, and then inform the
operator that a shock is advised.
defibrillate only for ventricular fibrillation
and very fast wide QRS complex tachycardias
(usually over 180/bpm)
used only in pulses and apneic patients.
Physio Control Life Pack 12 Zoll “M” Series
HP CodeMaster 100
Paramedics are very adept
at placing IV’s
IV access should not
prolong scene times in a
trauma patient, especially
when “Load and Go”
criteria are present
Spinal Immobilization ABC’s
The preservation of integrity of the spinal column
is of paramount importance in the field.
C-Spine stabilization and airway assessment are
Manual stabilization of the neck is not released until
the patient has been transferred and securely
strapped to a board.
Air Medical Transport
Association of Air Medical Services (AAMS)
Domestic: 362 air medical providers
International 23 air medical providers
Helicopter cost: $1-5 million
• annual operating cost: $2 million
827 per program
1997 - survey of 126 United States air medical
Clinical Use of Helicopters
150-200 mile range
Two major types of helicopter missions
(1) Trauma/medical scene responses (30%)
(2) Interfacility transfers (70%)
Can be based at a hospital or another
location near your service area.
Do not require a runway for takeoff and
Capable of landing in relatively small and
Usually ready for takeoff in a matter of
Future of EMS
EMS will represent the intersection of public safety, public health, and
health care systems.
EMS will continue to be diverse at the local level.
As a component of health care systems, EMS will be influenced significantly
by their continuing evolution.
There will be increasing need for information regarding EMS systems and
It will be necessary to continue to make some EMS system-related
decisions on the basis of limited information.
The media will continue to influence the public’s perception of EMS.
Federal funding/financial resources will be decreasing.
To make good decisions, public policy makers will need to be well-informed
about EMS issues.
NHTSA agenda guidelines: www.nhtsa.dot.gov/people/injury/ems/agenda/emsbro.html